Inspection on 10/08/05 for 92 Black Prince Avenue

This inspection was carried out on 10th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

92 Black Prince Avenue 23/11/06

92 Black Prince Avenue 30/12/05

92 Black Prince Avenue 13/02/05

92 Black Prince Avenue 20/04/04

Similar services:

Manor Court

Agnes House

The Manor House

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Applegarth

Thornham Grove

Hunter`s Lodge

Conifer Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 92 Black Prince Avenue Market Deeping Lincolnshire PE6 8LU Lead Inspector Mick Walklin Unannounced 10 August 2005 11:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 92 Black Prince Avenue C53-C04 S2501 92BlackPrinceAvenue V243810 100805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 92 Black Prince Avenue Address Market Deeping Lincolnshire PE6 8LU Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01778 344215 Sense East Miss Danielle Short Care home only 2 Category(ies) of SI Sensory Impairment (2) registration, with number of places 92 Black Prince Avenue C53-C04 S2501 92BlackPrinceAvenue V243810 100805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 13 February 2005 Brief Description of the Service: 92 Black Prince Avenue is a four bedroomed end of terrace house with an enclosed rear garden, situated on an estate. Two residents live at the home. At present, one of the bedrooms is used as a staff sleep-in room, and one is used as an office. The home is one of a number in the area managed by SENSE East, who provide specialist homes for life for people with either single or dual sensory impairment who may also have additional learning or physical disabilities. It is located a quarter of a mile away from a local supermarket, and Market Deeping town centre is approximately one mile away. The town centre contains a range of shops, pubs, banks and food outlets. The home is close to the Peterborough to Bourne bus route with regular services, and they also have sole use of a people carrier. 92 Black Prince Avenue C53-C04 S2501 92BlackPrinceAvenue V243810 100805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days, and lasted a total of 7 hours. The main method of inspection used was called case tracking which involved tracking the care that the two residents receive through the checking of their records, discussion with them, the care staff and observation of care practices. A tour of the premises was conducted with the manager, and documentation was inspected. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 92 Black Prince Avenue C53-C04 S2501 92BlackPrinceAvenue V243810 100805 Stage 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 92 Black Prince Avenue C53-C04 S2501 92BlackPrinceAvenue V243810 100805 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 & 4. There are good procedures for the assessment and admission of residents to the home, which ensure that staff have the information necessary to meet the needs of residents. EVIDENCE: One resident has been admitted from another SENSE East home over the past year. Assessment information and care plans were transferred from the previous home, and provided detailed information relating to the care needs of the individual. There was a structured transition process where he was able to visit on several occasions prior to admission for meals and to participate in activities, before an overnight stay. The home has an admission policy, which is contained in the Statement of Purpose. This includes the criteria for admission, the referral procedure and the admission procedure including assessment. The home also has detailed good practice guidelines, which outline the referrals procedure. 92 Black Prince Avenue C53-C04 S2501 92BlackPrinceAvenue V243810 100805 Stage 4.doc Version 1.40 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 & 10. Care plans and risk assessments are detailed and well organised, providing staff with a wide range of information in order to meet the needs of the residents. EVIDENCE: Both care plans had been recently updated, with six-monthly review dates included. The previous reviews had involved parents and placing social workers, as well as the home and day placement, and detailed progress reports had been prepared for the review. Care plans contain a wide range of information and assessments relating to daily living needs, likes and dislikes and choices. There are good risk assessments covering daily activities, enabling residents to live as independently as possible whilst minimising risks. There are detailed behavioural management plans and communication plans, and residents have excellent daily logs that travel with them to day services, ensuring continuity of care. Staff continually offered choices to the residents, and used a variety of techniques including pictures, signing and objects of reference to ascertain preferences. 92 Black Prince Avenue C53-C04 S2501 92BlackPrinceAvenue V243810 100805 Stage 4.doc Version 1.40 Page 9 Confidentiality is covered during induction, and staff were aware of their responsibilities. 92 Black Prince Avenue C53-C04 S2501 92BlackPrinceAvenue V243810 100805 Stage 4.doc Version 1.40 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 17. There are excellent educational, occupational and leisure activities available for residents, so that they have a varied and stimulating timetable. EVIDENCE: Both residents attend Peterborough Resource Centre (PRC) in Werrington, and has an allocated personal tutor. Residents participate in the Award Scheme Development and Accreditation Network Towards Independence (ASDAN), which enables residents to work towards specific goals and awards. Each activity at PRC has written aims and objectives, and progress reports are provided for reviews. PRC closes for 3 weeks in the summer, and residents have commenced a program of daily activities and outings. A new resource centre is due to open in Bourne in January 2006, and this will offer better facilities for residents. Hobbies and interests are well documented in care plans. The residents have dedicated use of a people carrier, which is situated on site, and regular outings are planned throughout the year. The activity timetable is varied, using many local facilities, and residents have had holidays in York and Blackpool this year. Staff use picture boards or picture books to communicate the timetable for the day to residents. 92 Black Prince Avenue C53-C04 S2501 92BlackPrinceAvenue V243810 100805 Stage 4.doc Version 1.40 Page 11 At the time of the last inspection it was recommended that a larger screen TV be purchased, as both residents have visual problems, and this has now been purchased. Catering arrangements are of a domestic nature, and flexible in nature to accommodate planned or unplanned activities. There is a four-week menu plan in place for guidance, and staff are recording food likes and dislikes as part of a review of these. Residents are involved in shopping and the preparation of food with support from staff. 92 Black Prince Avenue C53-C04 S2501 92BlackPrinceAvenue V243810 100805 Stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 20. There are good arrangements with local health providers so that the health needs of residents are met. Medication procedures ensure that medication is administered safely. EVIDENCE: Both residents are registered with the local GP surgery, although one refuses to attend medical appointments. One resident has annual ophthalmic checks, but the other has refused to attend ophthalmology and audiology, although a team from SENSE East have conducted their own assessment. Both have sixmonthly medication reviews. There are satisfactory arrangements for dental care. Speech and Language Therapy input is available as required. Medication storage and administration arrangements are safe. Neither resident self-medicates. A Pharmacist visited the home in February, and no issues were identified. The manager conducts regular audits of medication, and is responsible for ordering. There are good stocktaking arrangements. All staff are trained in the administration of medication by an external pharmacist. 92 Black Prince Avenue C53-C04 S2501 92BlackPrinceAvenue V243810 100805 Stage 4.doc Version 1.40 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23. There are good procedures for dealing with complaints and allegations of abuse, to ensure that resident’s concerns are acted upon, and that they are protected. EVIDENCE: There have been no complaints since the last inspection. There is a good stepby-step guide in symbols for residents wishing to make a complaint. The home’s ‘Resolving Issues’ guidelines now contain contact details for the Commission. There are detailed policies for the prevention of adult abuse, which also contain a flow chart for action. This policy is clearly cross-referenced with the Lincolnshire Adult Protection Committee procedures, a copy of which is displayed on the notice board. SENSE East has a Protection Committee, which reviews all reports of adult abuse within the organisation. Staff are given a questionnaire to complete at their annual appraisal, which checks their knowledge of the adult protection procedures. This information is then reviewed by a manager. Staff are clear on their responsibilities in reporting allegations or concerns. 92 Black Prince Avenue C53-C04 S2501 92BlackPrinceAvenue V243810 100805 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 The home provides a comfortable, well maintained and domestic environment for residents to live in. EVIDENCE: The home presents as an ordinary domestic dwelling, and is well decorated and maintained. It was clean and tidy at the time of the inspection. There have been continued improvements to the garden area, which provides a private and enclosed space for residents to enjoy. Mortise style locks were fitted to the lounge and kitchen doors, and these were removed by the second day of the inspection. 92 Black Prince Avenue C53-C04 S2501 92BlackPrinceAvenue V243810 100805 Stage 4.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 & 36. Residents benefit from a well trained and supported staff team. Recruitment and selection procedures are robust to ensure that residents are protected. EVIDENCE: The home is fully staffed at present, although staff holidays and the closure of PRC for 3 weeks is putting pressure on staff numbers. Staffing is on a 1:1 basis, with 2:1 for outings. SENSE East has introduced a central system for booking bank staff to replace the use of agency staff. A Team Leader has been recruited to support the manager, and it is now usually possible to have a male member of staff on each shift to reflect the gender of the residents. Recruitment and selection procedures are robust, with those staff files inspected containing the necessary information for the protection of residents. There are good induction and foundation programmes for new starters. Staff training is up to date. The training department produce a spreadsheet of training and supervision undertaken every quarter. One member of staff has completed NVQ level 2, with 2 studying towards this, and 2 enrolling later in the year. The manager has nearly completed NVQ level 4. Staff commented that training opportunities are good within the organisation. Staff receive supervision on a monthly basis, and are well supported by the manager. 92 Black Prince Avenue C53-C04 S2501 92BlackPrinceAvenue V243810 100805 Stage 4.doc Version 1.40 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 40, 41 & 42. The home is very well managed and organised with good health and safety systems in place, ensuring that residents are protected. EVIDENCE: Regular health and safety checks are undertaken by the Team Leader, and documentation was of a good standard. There are regular team meetings, and staff said that the manager is open and approachable. Sense East have a wide range of policies and procedures, which the manager indexed for ease of use. It is recommended that this be introduced to other Sense homes that do not have indexing. The home keeps inventories of furniture purchased by residents. 92 Black Prince Avenue C53-C04 S2501 92BlackPrinceAvenue V243810 100805 Stage 4.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 4 3 x x 3 Standard No 31 32 33 34 35 36 Score x x 3 3 3 4 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 92 Black Prince Avenue Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x 4 x 3 3 3 x C53-C04 S2501 92BlackPrinceAvenue V243810 100805 Stage 4.doc Version 1.40 Page 18 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 40 Good Practice Recommendations It is recommended that the managers excellent system for indexing policies and procedures be introduced in other Sense homes that do not have indexing. 92 Black Prince Avenue C53-C04 S2501 92BlackPrinceAvenue V243810 100805 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Unity House, The Point Weaver Road Off Whisby Road Lincoln, LN6 3QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 92 Black Prince Avenue C53-C04 S2501 92BlackPrinceAvenue V243810 100805 Stage 4.doc Version 1.40 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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